Level of Care Tools

Section 1915(b) Waiver: NC MH/IDD/SAS Health Plan (04/01/2013) identifies Medicaid 1915(b) services offered by Vaya. We also offer alternative medically appropriate, cost-effective services or settings as substitutes for some services or settings covered under this plan. Refer to the following links for service definitions and requirements:

Applied Behavior Analysis (ABA)

Currently, Applied Behavior Analysis (ABA) is not included in any Vaya benefit plan. However, Medicaid beneficiaries under age 21 may be eligible for ABA under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program if the request meets medical necessity and EPSDT criteria. ABA requires prior authorization. Learn more about Vaya’s coverage of ABA by reviewing our ABA Guidelines and ABA Provider Communication.

Vaya spends all Medicaid service dollars on services you deliver to our members. We do this by utilizing savings we achieve from efficient management of the 1915(b)/(c) Waiver to offer Medicaid (b)(3) services. Unlike regular Medicaid, (b)(3) services are not an entitlement, meaning they can only be reimbursed if service funding is available. Denials based on lack of funding may not be appealed. Current available (b)(3) services are:

N.C. Innovations is a 1915(c) Home and Community-Based Services (HCBS) Waiver for individuals with an IDD who would otherwise meet the intermediate care facility level of care. The 1915(c) N.C. Innovations Waiver allows individuals with an IDD, or a related qualifying condition, to receive services and supports in their own community and live as independently as possible.

NC Medicaid provides additional guidance for us to use in making authorization decisions. Guidelines for understanding individual level of support needs are set forth in the N.C. Department of Health and Human Services (DHHS) Operational Rules.

Vaya’s Non-Medicaid Benefit Plan includes public safety net services funded with state single-stream, federal and state block grants and county funds. Vaya is committed to making sure our limited resources benefit people who need it most.

People who meet “priority population” criteria based on screening, triage and referral information are first in line to receive these funds. Priority populations are groups of people with the most severe types of mental illness, severe emotional disturbances and substance use disorders with key complicating life circumstances, conditions and/or situations.

Non-Medicaid services are not an entitlement. Vaya can only fund services under this benefit plan within the limited resources allocated to us.

Children between age 5 and 20 who live in Vaya’s catchment area and who have documented diagnoses of an IDD and a mental health and/or substance use disability may be referred to the NC START Child program. NC START provides community-based crisis intervention and prevention services to children and their families. Services include: